Health care fraud is a prevalent issue in the United States. With people spending $2.27 trillion on health care in 2011, it only makes sense that some providers are fraudulent. Any individual or institution in the health care industry may commit fraud, including hospitals, individual providers, medical equipment suppliers, clinical laboratories and home health agencies.
But what exactly does health care fraud look like? Here are some common examples of fraudulent acts committed by health care providers.
When a provider bills a patient for a more expensive service than what was actually provided, it is upcoding. This is especially common for claims involving Medicare and Medicaid. An example of this is submitting a claim for treating a broken arm when the patient only has a sprain.
2. Phantom billing
Some health care providers bill for services they did not provide. The provider usually bills for non-existent services by charging for procedures that did not occur or completely fabricating claims using actual information from patients.
3. False diagnoses
Not all diagnoses are accurate or real. Sometimes, a doctor may falsify a diagnosis in order to conduct procedures that are not necessary. This usually leads to a long list of medically unnecessary services.
4. Illegal referrals
Certain providers bribe other providers to get patient referrals. This is a kickback, which is illegal according to the False Claims Act. Providers may use kickbacks to increase their profits.
5. Waiving deductibles or co-pays
If a provider does not make a patient provide a co-pay, it may be because he or she is defrauding the benefit plan or insurance carrier. The provider may try to over-bill these institutions. Not all instances of health care fraud are against patients.
There are many different types of health care fraud schemes. However, not every provider that is accused of being fraudulent deserves criminal charges.